Action Points

Note that this observational study of hospitals participating in a heart failure registry found that 30-day risk-adjusted mortality was a better proxy for long-term survival then 30-day readmission.

Be aware that this analysis does not imply that a 30-day survival metric would be superior to a readmission metric for all disease categories.

The benefit of going to a hospital performing well with regards to short-term survival persisted 5 years later, according to a longitudinal study that suggests looking at risk-adjusted mortality instead of readmissions was a better way for CMS to measure hospital performance.

Separating U.S. hospitals into quartiles based on their performance in risk-adjusted 30-day mortality for heart failure admissions (medians of each quartile ranging from 8.64% to 10.75%), researchers determined that the higher this metric, the less likely patients were to survive by 5 years.

Case in point: the 73.7% rate of long-term survival among worst-performing hospitals versus 76.8% for the best (adjusted HR 1.14, 95% CI 1.10 to 1.18), reported Ambarish Pandey, MD, of University of Texas Southwestern Medical Center in Dallas, at the American College of Cardiology annual meeting. The study was simultaneously published online in JAMA Cardiology.

Another metric, the 30-day risk-standardized readmission rate (RSRR), is the primary quality metric currently used by the Centers for Medicare and Medicaid Services (CMS) to judge and incentivize each hospital, according to the investigators, who noted that the agency implemented the Hospital Readmissions Reduction Program to financially incentivize hospitals to cut down on readmissions for conditions including heart failure, acute MI, and pneumonia.

"As a result, there is an increasing drive to invest hospital resources in programs focused on reducing readmissions," they said. "While such programs may have led to a decline in readmission rates, there has been a significant and steady increase in [RSMRs] in heart failure over the same period."

Moreover, studies have failed to show that the RSRR truly captures in-hospital care quality and long-term outcomes in patients with heart failure or acute MI, Pandey's group added.

"Findings from our study suggest that hospital-level 30-day RSMR may be a useful metric for hospital performance and should potentially be weighted more in CMS financial incentive programs," they suggested.

ACC session panelist Lynne Warner Stevenson, MD, of Vanderbilt University Medical Center in Nashville, called the study "very elegantly done." She said she agreed that mortality was more valid as a metric than readmissions, recalling data suggesting that more than 60% of recent improvements in the latter can be attributed to upcoding by hospitals.

The investigators used the Get With The Guidelines-Heart Failure (GWTG-HF) Registry to gather data on 106,304 patients, ages ≥65, hospitalized for heart failure in 2005-2013. The cohort was 54.1% women and 79.6% white, with a median age of 81.

Heart failure type turned out to interact with the association between 30-day RSMR-based hospital performance and risk of long-term mortality, Pandey's group observed, with the connection being stronger among heart failure patients with reduced ejection fraction (HFrEF) than peers with preserved ejection fraction (HFpEF).

In addition, hospitals with the best RSMRs tended to use more implantable cardioverter defibrillation and cardiac resynchronization therapy; they were also more likely to have cardiac surgery and percutaneous coronary intervention available.

"Taken together, these findings suggest that greater use of evidence-based, life-prolonging therapies and greater postdischarge follow-up care may contribute, at least in part, to better long-term survival at hospitals with low 30-day RSMRs," the authors concluded. They added that this is "supported by the stronger association between hospital-level 30-day RSMR and long-term outcomes in patients with HFrEF who can benefit from life-prolonging therapies versus those with HFpEF and limited mortality-improving treatment options."

Caveats to the analysis are its observational nature and its limited generalizability given that investigators only included hospitals participating in the GWTG-HF registry.

The GWTG-HF program is supported by the American Heart Association (AHA), and has received funds from Medtronic, GlaxoSmithKline, Ortho-McNeil Pharmaceutical, and the AHA Pharmaceutical Roundtable.

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